Nicotine Dependence and Loss of Autonomy among Greek Adolescent Smokers: A Countrywide Cross-Sectional Study

Int J Environ Res Public Health. 2020 Nov 5;17(21):8191. doi: 10.3390/ijerph17218191.


Nicotine dependence is one of the main reasons for the continuation of smoking among adolescents. Loss of autonomy (LOA) is a measure of dependence. This study is the first to investigate LOA and its determinants among Greek adolescents. In 2013, 13-to-15-year-old middle-school students were selected by multi-stage clustered sampling. LOA was evaluated with the Hooked-on-Nicotine Checklist (HONC). Multiple univariate analysis was used to assess the association between adolescent demographics, smoking habits, and loss of autonomy. Three-hundred thirty-nine current smokers responded to the questionnaire (response rate: 82.3%). Of these respondents, 51.2% were male and 88.8% reported at least one LOA symptom. The mean HONC score was 4.13/10 (95% CI: 3.82-4.45). Higher scores were negatively associated with lower smoking frequency (cumulative odds ratio (cOR): 0.240, 95% CI: 0.144-0.400) and positively associated with lower age at first cigarette (cOR: 2.29, 95% CI: 1.38-3.82). Female gender was significantly associated with the prevalence but not the degree of LOA. Overall, the prevalence and the degree of nicotine dependence among adolescent smokers in Greece is similar to other countries. Frequent smoking and initiation of smoking at a younger age are linked to nicotine dependence, although it was not possible to make causal inferences. The relationship between nicotine dependence and gender remains unclear.

Keywords: Greece; HONC; adolescent; cigarette; loss of autonomy; nicotine dependence; smoking; tobacco.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Cross-Sectional Studies
  • Female
  • Greece / epidemiology
  • Humans
  • Male
  • Nicotine
  • Personal Autonomy*
  • Smokers
  • Smoking / epidemiology*
  • Tobacco Use Disorder / epidemiology*


  • Nicotine